Ebola: Infection Control Needs Rethink

Protocols for protective gear now under scrutiny.

Discussant: Frank Esper, MD Please click the bottom right corner for full screen.

by John Gever John Gever,Managing Editor, MedPage Today
October 13, 2014

CDC Director Tom Frieden, MD, acknowledged that the case of a Dallas healthcare worker who developed Ebola "does change substantially how we address" efforts to prevent additional infections.

During a press call with reporters on Monday, Frieden insisted that the case did not undermine the prevailing theories of how Ebola is transmitted. But it does suggest that existing infection control measures may not be adequate.

He also said he "would not be surprised if we saw additional cases" among healthcare workers at Texas Health Presbyterian Hospital in Dallas where the current patient worked, and where the first U.S. case was diagnosed and later died.

The still unidentified female Texas Health Presbyterian worker is the first person to become infected with Ebola in the U.S. Other individuals treated for Ebola in U.S. hospitals contracted the disease in West Africa.

Officials said on the weekend that she developed a low-grade fever on Friday and was quickly placed in isolation. On Sunday, lab tests confirmed that she was infected with Ebola. The hospital has not released information on her clinical condition; Frieden said Monday he had been told she is "clinically stable" but declined to give details, referring questions back to the hospital.

Frieden said investigators are now closely monitoring procedures for donning and removing protective gear in the hospital. Officials are also considering whether other types of gowns, masks, gloves, and other equipment might reduce the risk of exposure during changes, he said.

But he suggested that full hazmat suits are almost certainly not the answer because of the difficulties they create for patient care and for the workers themselves.

Frank Esper, MD, an infectious disease specialist at University Hospitals Case Medical Center in Cleveland, told MedPage Today that workers must strike a balance between self-protection and their job responsibilities.

"Some institutions are opting to use a full-body hood" instead of face shields and masks, he said. This provides "a lot of protection for the healthcare worker.

"The biggest problem with a lot of this," he continued, "is that we're very compassionate when we try to take care of our patients. We want to be able to relate to them, we want them to feel secure."

He said it makes patients nervous to "see all these hoods and gowns and face masks" and that it runs counter to the goal of providing reassurance to patients.

During press briefings on Sunday, CDC and local officials said they didn't know exactly how the Dallas nurse had been exposed. She was said to have worn protective gear at all times while caring for the Liberian patient, Thomas Eric Duncan. But CDC director Tom Frieden, MD, said there must have been a "breach in protocol" at some point.

On the Monday press call, Frieden reiterated those conclusions.

He added that monitoring of 48 individuals who definitely or possibly had contact with Duncan prior to his hospital admission was continuing and that, as of now, none had shown signs of illness. Monitoring has now been extended to healthcare workers at Texas Health Presbyterian who were involved in Duncan's care.

Officials in Dallas have not identified the currently infected worker. The Dallas Morning Newssaid she is a nurse and that it had established her identity "through public records, social media sites, a state nursing database and interviews" but did not publish her name because the hospital had not confirmed it.

The newspaper said the nurse was a 2010 graduate of Texas Christian University and was described by friends as "big-hearted [and] compassionate."

Another individual identified as a "close contact" of the woman was also placed in isolation at Texas Health Presbyterian over the weekend. Officials said this person, who also has not been identified, was the only one believed to have come in contact with the infected nurse while she was symptomatic.

On Monday, Texas State Health Services Commissioner David Lakey, MD, said an initial cleaning of the woman's apartment had been completed. However, her dog is still there under observation and a final definitive cleaning is waiting for officials to find another location for the dog. There is no plan to euthanize it as was done for a dog belonging to the Spanish nurse who contracted Ebola in Madrid.

Asked about stiffer travel restrictions for individuals who, like Duncan, may have been exposed to Ebola in West Africa, Frieden indicated that he was satisfied with current policies.

But all 91 passed fever checks and detailed questioning about their time in the Ebola hot-zones and were allowed on their way, he said.

He said an outright ban on entry for everyone coming from those areas could undermine the best way to protect Americans: to "stop it at the source." Such a ban would complicate aid efforts to the stricken nations and make it harder to contain the epidemic there. That in turn would make it more likely that Ebola would continue to be exported from the region, Frieden suggested.

Screening like that at JFK is to commence this week at airports in Atlanta, Chicago, Washington, and Newark. Collectively, the five airports have been the point of entry for 94% of passengers traveling from the three West African nations officials said last week.

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